Lc. Kleinman et al., ADHERENCE TO PRESCRIBED EXPLICIT CRITERIA DURING UTILIZATION REVIEW -AN ANALYSIS OF COMMUNICATIONS BETWEEN ATTENDING AND REVIEWING PHYSICIANS, JAMA, the journal of the American Medical Association, 278(6), 1997, pp. 497-501
Context.-Utilization review (UR) seeks to improve quality and cost-eff
iciency of health care. However, how well the process works in practic
e has not been assessed. Objective.-To describe the outcomes of a samp
le of physician reviews in terms of the explicit criteria that the UR
was designed to implement. Design.-Retrospective analysis of transcrip
ts of precertification reviews. Participants and Setting.-California p
hysicians employed by a UR firm conducted 96 interviews from April 199
0 to July 1991 with attending physicians who had proposed to insert ty
mpanostomy tubes on a patient younger than 16 years and whose proposal
s had been found to be inappropriate on an initial screen. Main Outcom
e Measures.-The appropriateness rating assigned to each case by the ph
ysician-reviewer and by the investigators using explicit criteria. Log
istic regression identified factors associated with the reviewers' rec
ommendations to perform surgery and with recommendations at variance f
rom the criteria. Results.-The reviewers recommended 78% of cases for
surgery, of which only 29% were supported by the criteria or had exten
uating circumstances. The criteria. concurred with all 30 of the revie
wers' recommendations against surgery. Two factors, female sex (odds r
atio [OR], 8.2; 95% confidence interval [CI], 1.2-53.8) and previous t
ympanostomy tube insertion (OR, 30.9; 95% CI, 2.4-394.8) were associat
ed with reviewer recommendations in favor of surgery that were at vari
ance from the criteria, despite the lack of evidence for either as a m
itigating circumstance. Conclusion.-Physician reviewers were more leni
ent than the explicit criteria that the reviews were designed to imple
ment. In no cases did the reviewers depart from the criteria's recomme
ndations in favor of surgery.